Management of Patients with Neurologic Dysfunction - MS61

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency."

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:

52 mm Hg.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered.

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?

Administer medications at exact intervals ordered.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?

Cluster

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?

Decerebrate posturing and loss of corneal reflex

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings?

Excessive urine output and decreased urine osmolality

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate

Following a transsphenoidal hypophysectomy, a nurse should assess a client for which condition?

Hypocortisolism

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Increased ICP is 12 mm Hg.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

Infection

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply.

Keep a food diary maintain a headache diary

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Lactated Ringer's

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.

Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway

A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply.

Medication regimen Appointments for chemotherapy or radiotherapy Adverse effects of chemotherapy or radiation and techniques for managing them nutritional support

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 mL/h

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Notify the physician of a possible cerebrospinal fluid leak.

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?

Oliguria and serum hyponatremia

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Phenobarbital

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?

Pituitary carcinoma

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

The CPP is low.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Turn the client to the side during a seizure and do not restrain movements

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

Urinary tract infection

Which method is used to help reduce intracranial pressure?

Using a cervical collar

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?

Verapamil (Calan)

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

promote carbon dioxide elimination.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

vasodilation